Surgical management of pancreatic pseudocyst.

BACKGROUND: Pancreatic pseudocysts were once considered to be an unusual complication of acute chronic and traumatic pancreatitis. METHODS: This work was made in order to study the results of the operative methods in 24 patients with acute chronic and traumatic pancreatic pseudocysts, treated by external or internal drainage during the years 1990-1995 at the Athens Red Cross Hospital and compare these results with those of international literature. Pain was the common symptom for all patients. Gallstones were the most important aetiological agent in thirteen of the 24 patients, while alcoholic pancreatitis was diagnosed in only 6 of them. Fifteen patients (62.5%) were treated by surgical drainage or resection and 9 patients (37.5%) were treated by observation, one by percutaneous and one by endoscopic drainage. The rest had small cysts (less than 5 cm) and were treated by observation. RESULTS: The most frequent complication of internal cyst drainage was upper gastrointestinal haemorrhage. The rate of mortality was 7%. CONCLUSIONS: Anatomical considerations dictate the choice of operation. Cystogastrostomy, for example is inappropriate unless the stomach is closely applied to the front of the cyst. We preferred cystojejunostomy Rouen-y because the Roux loop can be anastomosed to the lower part of the cyst. Cystoduodenostomy should be reserved for pseudocyst in the head of the pancreas. Resection is an alternative to internal drainage for chronic pseudocyst of moderate proportions, for those that have largely replaced a portion of the pancreas.     

胰腺假性囊肿的治疗研究

目的评价胰腺假性囊肿不同治疗方式的效果。方法对1990年1月至2003年4月收治的128例胰腺假性囊肿不同处理方式的效果及并发症进行回顾性分析。结果128例患者中30例未行手术治疗,其中3例失访,27例在随访期间囊肿自行吸收。B超引导下经皮置管引流组22例,有效率60%。外科手术治疗76例,死亡率5.3%(4/76),手术方式包括:外引流10例,死亡率20%(2/10);囊肿胃吻合术14例,术后消化道出血的发生率为42.9%(6/14),死亡率7.1%(1/14);囊肿空肠Roux-en-Y吻合术28例,术后消化道出血的发生率10.7%(3/28),死亡率0%;囊肿十二指肠吻合术3例,死亡率33.3%(1/3);假性囊肿切除术21例。结论B超引导下经皮置管引流创伤小,操作相对简单,但尚未能完全取代传统手术。囊肿胃吻合术后消化道出血的发生率高于囊肿空肠Roux-en-Y吻合术。对于怀疑为真性囊肿或囊腺癌者,应尽量手术切除。     

非胰腺手术后胰腺假性囊肿的治疗

目的探讨非胰腺手术后胰腺假性囊肿的治疗方法。方法对近11年来治疗的28例非胰腺手术后胰腺假性囊肿进行回顾性临床分析。结果保守治疗4例。B超引导下经皮多次穿刺10例(其中穿刺后置管外引流3例)。手术行外引流6例,内引流8例。1例外引流无效后,改行内引流。28例均痊愈出院。结论手术后胰腺假性囊肿应采用个体化的治疗原则,早期应采取保守治疗、穿刺抽液或外引流,内引流可作为治疗的最后选择。     

Operative strategies in the management of mediastinal pancreatic pseudocyst

Thirty-four cases of mediastinal pancreatic pseudocyst have been previously reported. Among the 32 previous reports with operative or autopsy analysis, communication has been identified in 30. Even when this communication has been quite small between the mediastinal fluid collection and the pancreas, the recommended operative strategy has been enteric drainage directly to this communicating tract. We report the case of a patient with a mediastinal pancreatic pseudocyst in whom the communication between the pancreas and the pseudocyst was not located. The condition was managed by drainage of the mediastinal pseudocyst with decompression of the main pancreatic duct by means of a longitudinal pancreaticojejunostomy in a patient with chronic pancreatitis.     

The differentiation between pancreatic neoplastic cysts and pancreatic pseudocyst.

The number of small and often asymptomatic cystic lesions detected in pancreas has increased during the last decade. Historically the vast majority of the pancreatic cystic lesions were considered pseudocysts, but in recent series the incidence of various neoplastic cysts, such as intraductal papillary mucinous neoplasm, serous cystadenomas and cystic endocrine tumours, has increased. The possible malignant potential in these cystic neoplasms warrants careful diagnostic workup to choose the optimal treatment for each patient. Patient's age, symptoms and a possible history of acute or chronic pancreatitis with known aetiology together with high quality imaging studies are important in the differential diagnosis between pseudocysts and neoplastic cysts. Endoscopic ultrasound, cyst fluid analysis and positron emission tomography may be used in selected patients, but the accuracy of these methods needs further investigation.     

胰腺假性囊肿的诊治体会

目的 总结胰腺假性囊肿的诊治体会。方法 回顾性分析46例胰腺假性囊肿患者的临床资料，7例保守治疗，行内引流术12例，外引流术9例，序贯式内外引流术5例，胰腺部分切除术13例。结果 保守治疗者均痊愈，无复发；行内引流术者中有1例发生肠瘘，其余11例恢复良好无复发；行外引流术1例出现胰瘘，2例复发；行胰腺部分切除术者有1例出现胰瘘，其余恢复良好。结论 根据病情和病程选择合适的术式是治疗胰腺假性囊肿的关键。     

Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up

Background

Literature on long-term outcome after endoscopic management of pediatric pancreatic pseudocyst is not available. The aim of the present study is to report long-term outcome after endoscopic drainage of pancreatic pseudocyst in children.

Methods

Nine patients younger than 15 years, subjected to endoscopic pseudocyst drainage, were included in this study (between 1994 and 2004). Eight patients were subjected to endoscopic cystogastrostomy and stenting, whereas 1 patient was subjected to cystoduodenostomy and stenting. A follow-up of patients was done at 1 month and at 2 to 10 years after drainage. Endoscopic retrograde cholangiopancreatography (ERCP) was done in 2 patients at the time of drainage, and it was repeated in both the patients at the time of final follow-up.

Results

Mean age of the patients was 9.6 years. Trauma was the most common cause (n = 8). Mean follow-up of these patients was 5.7 years (2-10 years). No recurrence was seen in any patient. Endoscopic retrograde cholangiopancreatography revealed complete pancreatic duct block in prevertebral region in 2 posttraumatic patients, and it was persisting on repeat ERCP at final follow-up.

Conclusions

Endoscopic drainage of pancreatic pseudocyst is safe in children with a very good long-term outcome. Pancreatic duct block seen on ERCP may not be clinically important on long-term follow-up.     

Blunt pancreatic trauma and pseudocyst: management of major pancreatic duct injury

When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.     

Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst.

The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p less than 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p less than 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.     

The surgical treatment of pancreatic pseudocyst

Experience of surgical treatment of 370 patients with chronic pancreatitis, complicated by pancreatic pseudocyst occurrence, was analysed. Differentiational approach to operative intervention permitted to reduce the frequency of conduction of resections by 21.5%, replacing them by enhancing the quantity of drainage operations, what permitted to lower the occurrence of postoperative complications and to improve late follow-up result of treatment.     

Pancreatic pseudocyst in children: the impact of management strategies on outcome

Introduction

Persistent pancreatic pseudocysts (PPs) are rare in childhood and management tends to be individualized. The purpose of this review is to determine the impact of different management strategies and to analyze their effects on patient outcomes.

Methods

An institutional review board-approved retrospective chart review was performed on children younger than 18 years who had PP diagnosed between January 1976 and December 2003.

Results

There were 24 patients, 13 male and 11 female, with a mean age 10.7 years (range, 2-17 years). The mean PP size was 5.8 cm (range, 1.7-20 cm). Posttraumatic pseudocysts were identified in 11 children. The etiologies of 13 nontraumatic PP were idiopathic (6), familial pancreatitis (4), drug-induced (1), cholelithiasis (1), and bifid duct (1). All patients were symptomatic at diagnosis. Resolution of pseudocysts without operative intervention occurred in 7 (29%) of 24 patients. The mean time to operation for the remaining 17 children (71%) was 13.1 weeks (range, 6-36 weeks), with indications for intervention including persistent/recurrent abdominal pain (17), failure to thrive (9), infected PP (1), and ruptured PP (1). Surgical therapies for 13 of 17 patients consisted of cystogastrostomy (8), cystojejunostomy (2), longitudinal pancreaticojejunostomy (2), and Frey's procedure (1). Four patients underwent pancreatic sphincterotomy and stenting, 2 of whom also had image-guided pseudocyst drainage. The intervention-related mortality and morbidity rates were 0% and 11%, respectively, for children undergoing surgical therapies. The morbidities included pancreatic leak (1) and wound infection (1). Etiology of the PP had a significant influence on the need for intervention (traumatic, 45%; nontraumatic, 92%; P = .02); however, patient age, size, and location of the PP had no significant effect. All 24 patients continued to do well at mean follow-up of 73.3 months (range, 6 weeks-25 years). One patient with idiopathic pancreatitis has since developed insulin-dependent diabetes. All 4 patients with familial pancreatitis had their chronic pain improved without long-term narcotic therapy.

Conclusion

The treatment of PPs in children is dependent on etiology, where pseudocysts from nontraumatic etiologies are more likely to require and benefit from surgical interventions, whereas pseudocysts from traumatic etiology are more amenable to conservative management. For children with persistent symptoms or interval complication, surgical therapy is safe and effective.     

Conservative treatment as an option in the management of pancreatic pseudocyst

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.     

Spontaneous gastric decompression of pancreatic pseudocyst.

Spontaneous resolution of pancreatic pseudocysts is being reported with increasing frequency. Although many mechanisms have been proposed one that is not frequently recognized is spontaneous decompression into the gastrointestinal tract. This case report demonstrates the mechanism of spontaneous resolution of a traumatic pancreatic pseudocyst, several weeks after injury, through fistulization between the pseudocyst and the stomach. Spontaneous resolution of a pancreatic pseudocyst after a transient episode of diarrhea should suggest the mechanism of gastrointestinal decompression of the pseudocyst.     

胰腺假性囊肿的外科治疗：附89例报告

目的：探讨胰腺假性囊肿的治疗策略。方法：回顾性分析近5年湘雅医院普通外科收治的89例胰腺假性囊肿临床资料，根据囊肿部位、形成时间及囊壁厚度，采用非手术治疗20例，经皮囊肿穿刺引流7例，开腹手术62例（外引流8例、内引流45例、囊肿切除9例）。结果： 全组无死亡病例，手术后并发症发生率15.9%，随访3个月至5年，复发率5.6%。结论：胰腺假性囊肿的治疗宜根据情况采用不同方式，非手术治疗适于无并发症者;急诊手术应选择外引流;囊壁成熟者，选择内引流术疗效好。